Acute Knee Injuries: Use of Decision

Rules for Selective Radiograph

Ordering
HOWARD B. TANDETER, M.D., and PESACH SHVARTZMAN, M.D., Ben-Gurion University of the
Negev, Beer-Sheva, Israel
MAX A. STEVENS, M.D., University of Iowa Hospitals and Clinics, Iowa City, Iowa
Am Fam Physician. 1999 Dec 1;60(9):2599-2608.

Family physicians often encounter patients with acute knee trauma. Radiographs of injured
knees are commonly ordered, even though fractures are found in only 6 percent of such patients
and emergency department physicians can usually discriminate clinically between fracture and
nonfracture. Decision rules have been developed to reduce the unnecessary use of radiologic
studies in patients with acute knee injury. The Ottawa knee rules and the Pittsburgh decision
rules are the latest guidelines for the selective use of radiographs in knee trauma. Application
of these rules may lead to a more efficient evaluation of knee injuries and a reduction in health
costs without an increase in adverse outcomes.

Family physicians are frequently called on to evaluate patients who have acute knee injuries.1 Each
year, knee trauma is also responsible for an estimated 1.3 million visits to emergency departments in
the United States.2 The anatomic characteristics of the knee, its exposure to external forces and the
functional demands placed on the joint may explain the frequency of injury.

Standard emergency medicine textbooks imply that radiographs should be routinely obtained for every
patient who presents with a knee injury.3–5 Consequently, radiographs are among the most commonly
ordered imaging studies for traumatic injury to the knee joint.6,7 This situation persists despite the
absence of clear supporting data and the fact that only 6 percent of patients with knee trauma have a
fracture.6–9

Even though emergency department physicians can discriminate clinically between fracture and
nonfracture, they order radiographs for most patients with acute knee injury. Reasons for the
unnecessary use of radiography include fear of lawsuits, failure to obtain an adequate history and
expectations on the part of patients.10–12

Overuse of radiologic studies has become a significant economic problem in the United States.11,13

Although knee radiographs are relatively inexpensive, high volume of a low-cost test has the same
overall financial impact as low volume of a high-cost procedure.14,15 Unnecessary radiation exposure

and prolonged waiting times are other reasons to decrease the use of radiologic studies. The application
of decision rules for the selective ordering of radiographs may result in a more efficient evaluation of
patients with acute knee injuries and may reduce the use of radiography in these patients.

This article briefly reviews the anatomy of the knee joint as well as the most common knee fractures
and ligament injuries. Clinical decision rules for ordering diagnostic radiographs following knee injuries
are also discussed, with special emphasis given to the guidelines developed in Ottawa, Ontario, and
Pittsburgh, along with their potential use in the management of knee injuries.

Anatomy of the Knee

The anatomy and function of the knee

are quite complex, and only the basics
are described in this article. The
osseous structures of the knee include
the distal femoral condyles, proximal
tibial plateau and patella (Figure 1). The
tibial plateau articulates with the femoral
condyles, and the patellofemoral groove
(located anteriorly between the femoral
condyles) accepts the patella. The tibia
and patella do not articulate. The gliding
motion of the patella across the femur
allows smooth extension at the knee
and increases the mechanical
advantage of the quadriceps.

The extra-articular muscle-tendon units

include the quadriceps and patellar
tendons (responsible for knee
 extension), medial and lateral
hamstrings (chiefly responsible for knee
flexion), gastrocnemius muscle,
popliteal ligament and iliotibial band
(Figure 2).

The extra-articular ligamentous

structures include the tibial and fibular
collateral ligaments (Figure 1). These
ligaments act as the principal extra-
articular static stabilizing structures (i.e.,
they provide stability for the medial and
lateral aspects of the knee).

The intra-articular structures

include the medial and lateral
menisci and the anterior and
posterior cruciate ligaments
(Figure 1). The menisci are
fibrocartilaginous wedges that
rim and cushion each
tibiofemoral articulation. The
anterior and posterior cruciate
ligaments provide stability for
the knee joint.

Knee Fractures
Fractures may occur in the
patella, femoral condyles or tibial plateau.16 Patellar fractures are divided into transverse, vertical, upper
pole, lower pole, comminuted and osteochondral fractures (Figure 3). Each type can be undisplaced or
displaced (Figure 4). The two main mechanisms of
patellar fracture are direct trauma to the anterior
aspect of the knee or a powerful contraction of the
quadriceps muscle (transverse, upper pole and
lower pole fractures).

Radiographs are essential to assess traumatic

patellar injury. In addition to antero-posterior,
notch and lateral views, Merchant and infrapatellar
views with the knee in 45 degrees of flexion may
be necessary to identify an osteochondral
fragment (Figure 5).
 Fractures of the femoral
condyles involve the distal 9
to 15 cm of the femur (Figure
6). Both the diaphyseal and
metaphyseal regions may be
involved. Fractures may also
show intraarticular extension.

Most condylar fractures

occur as a result of motor
vehicle accidents. Other
causes include falling on a flexed knee or falling from a height. In young people, higher energy is
necessary for a fracture to occur; consequently, more soft tissue damage is also present. In older
patients with osteoporosis, less energy is needed to produce a fracture; therefore, less associated soft
tissue damage is present.

Fractures of the tibial

plateau are of special
importance because they
occur in one of the most
important weight-bearing
areas (Figure 7). These
fractures may involve the
metaphysis, epiphysis
and/or articular cartilage.
The forces that produce
fractures in this area are
compression, valgus force
(outward twisting [away from the midline]) or a combination of both. The fractures primarily involve the
lateral plateau, the medial plateau or both structures (bicondylar fractures).

FIGURE 7.
Fractures of the tibial plateau. These
fractures can be comminuted (top) or
can be limited to the depression of
the tibial plateau, or they can also
involve the displacement of both
plateaus and can be associated with
fibular head fracture (bottom).
Knee Ligament Injuries
No validated rules have been formulated for the use of radiography in patients with suspected ligament
injuries, but a decision tree can be used as a guide (Figure 8).17 Although plain radiographs may be
useful in the initial diagnosis of these injuries, magnetic resonance imaging (MRI) is becoming the
preferred diagnostic method18 and is rapidly replacing other techniques as the study of choice for the
evaluation of knee injuries.19 However, the routine use of MRI has been questioned because of its
significant cost ($600 to $1,200) and the high accuracy of clinical examination in diagnosing some
injuries.20

Evaluation of Collateral Ligament Injury

FIGURE 8.

Suggested decision tree for the evaluation of collateral ligament injury. (RICE = rest, ice, compression and elevation)

Adapted with permission from Smith BW, Green GA. Acute knee injuries: Part II. Diagnosis and management. Am
Fam Physician 1995;51:800.
ANTERIOR CRUCIATE LIGAMENT

Rupture of the anterior cruciate ligament (ACL) is a serious injury, and the diagnosis may be missed.18
This type of injury can be produced by pure hyperextension or by a combination of valgus force and
external rotation of the tibia relative to the femur.

The immediate development of a hemorrhagic effusion is an important point in the history of ACL injury
(Figure 9). The stability of the ACL may be clinically assessed with the use of the Lachman test
(modified anterior drawer test). More than 90 percent of ACL injuries can be detected based on the
history and physical examination.17 However, even the best specialists may fail to recognize the joint
laxity of an ACL injury. Therefore, radiographic signs are useful in making the diagnosis.

FIGURE 9.

Fluid level (arrows) seen on a cross-table lateral radiograph. This indicates the
presence of hemarthrosis from injury of the anterior cruciate ligament.

ACL injury has three main radiographic signs: (1) avulsion of the
intercondylar tubercle (Figure 10), (2) anterior displacement of the tibia
with respect to the femur, termed the “radiographic drawer sign,” and
(3) Segond fracture (a thin sliver of bone avulsed from the proximal
lateral tibia with the lateral capsular ligament), termed the “lateral
capsular sign”16 (Figure 11). Note, however, that these radiographic signs are frequently absent in
patients with ACL injuries.

FIGURE 10.

Avulsion of the intercondylar tubercle (arrow), indicating injury of the anterior

cruciate ligament.

FIGURE 11.

Segond fracture (arrow), which is a cortical avulsion of the proximal lateral tibial
plateau that also involves the lateral capsule.

The gold standard for the diagnosis of ruptured ACL is arthroscopy.

Compared with this procedure, MRI has a diagnostic accuracy of more
than 90 percent. In addition, ultrasound examination has been shown
to be a useful and inexpensive mode of detecting a ruptured ACL in
the clinical setting of a traumatic hemarthrosis.21
POSTERIOR CRUCIATE LIGAMENT

Injuries of the posterior cruciate ligament (PCL) are relatively uncommon, apparently because this is
the strongest major knee ligament. The mechanism of isolated PCL injury is blunt trauma to the anterior
proximal tibia (“dashboard injury”).

Several maneuvers can be helpful in diagnosing PCL injuries (Figure 12). In one study,22 the gravity
sign near extension correctly diagnosed PCL injury in 20 of 24 patients, and active reduction of posterior
tibial subluxation correctly identified PCL injury in 18 of 24 patients. The gravity test is performed at 20
degrees of knee flexion. Neither maneuver requires anesthesia.

FIGURE 12.

Two maneuvers to detect posterior

cruciate ligament injury. (A) Gravity
sign near extension test. In a resting
position with the distal femur on a 15-
cm support and the heel resting on
the examination table (20 degrees of
flexion), the unsupported proximal
tibia displays a concave anterior
contour. (B) Active reduction of
posterior tibial subluxation. When the
patient raises the heel 2 to 3 cm, a
normal anterior contour is restored.

Nonetheless, clinical diagnosis

may be difficult, and
radiographic signs are important.18 The most common radiographic sign of PCL injury is avulsion at
the site of the ligament's origin on the posterior tibia (Figure 13). Less commonly, avulsion can be seen
at the site of PCL insertion at the medial femoral condyle. When the PCL fails, posterior sagging of the
tibia relative to the femur may be seen on the lateral radiograph.

FIGURE 13.

Avulsion at the site of origin on the posterior tibia (arrow), resulting from injury of
the posterior cruciate ligament.

MRI is accurate in diagnosing PCL injuries. It can also show associated

injuries of the ACL and medial collateral ligament (MCL), as well as
bone contusions.

MEDIAL COLLATERAL LIGAMENT

Knee injuries involving valgus force, with or without a rotational element, are suggestive of MCL injury.
The physical examination may demonstrate effusion or local soft tissue swelling and ecchymosis.18
Injuries to the MCL usually occur at the ligament's proximal origin. Therefore, tenderness is usually
localized along the distal femur and extends to the joint line.17

The major secondary radiographic sign of MCL injury is widening of the medial joint space. A lateral
tibial plateau fracture may also suggest MCL injury.

MRI demonstrates MCL injury as well as associated injuries of the medial meniscus, capsule and ACL.

LATERAL COLLATERAL LIGAMENTOUS COMPLEX

Injuries of the lateral collateral ligamentous complex (LCL) are estimated to account for only 5 percent
of all knee ligament injuries.18,23 Radiographic signs suggesting LCL injury include lateral joint space
widening and medial tibial plateau fracture.18

Decision Rules for Radiography in Acute Knee Injury

For several years, researchers have been working to design protocols that may reduce the number of
radiographs used in the evaluation of extremity injuries. A good example of a successful protocol is the
one now known as the “Ottawa ankle rules.”24–27 Protocols have also been designed for the radiologic
evaluation of knee injuries.28–30 The clinical decision rules created in Ottawa and Pittsburgh are the
best known guidelines for the appropriate use of radiographs in acute knee injuries (Table 1).
OTTAWA KNEE RULES

Investigators in Ottawa conducted a retrospective chart review of all patients with acute knee injuries
who presented to an emergency department over a 10-month period.8 The knees of 74 percent of
these patients were evaluated radiographically, but only 5.2 percent were found to have fractures. All
charts were evaluated for the presence of 11 clinical variables: age, gender, mechanism of injury (blunt
trauma or fall versus twisting), history of swelling, history of deformity, ability to ambulate (i.e., to walk
four steps), swelling, effusion, ligamentous instability, decreased range of motion and pain on palpation.

Logistic regression analysis found that a fall or blunt trauma mechanism of injury had a sensitivity of
92 percent and a specificity of 57 percent for the presence of a knee fracture.8 The addition of inability
to ambulate and age (younger than 12 years and older than 50 years) improved the specificity. The
prospective part of the study found that the combination of all three criteria was 100 percent sensitive
and 79 percent specific for knee fracture.29

In a later study,27 attending physicians in the emergency departments of two university hospitals
assessed every adult patient with an acute knee injury for 23 standardized clinical findings. The Ottawa
knee rules were derived from this study. The presence of one or more of these findings would have
identified the 68 fractures in the study population. Furthermore, application of the Ottawa knee rules
would have led to a 28 percent relative reduction in the use of radiography in the study population.

A prospective validation of the Ottawa knee rules was published in 1996.2 Attending emergency
department physicians assessed each patient for standardized clinical variables and determined the
need for radiography based on the decision rules. The rules were assessed for their ability to correctly
identify the criterion standard, which was fracture of the knee. The study found that the decision rules
were 100 percent sensitive for identifying knee fractures, were reliable and acceptable, and had the
potential to allow physicians to reduce the use of radiography in patients with acute knee injuries. If the
decision rules were negative, the probability of a knee fracture was zero percent.

PITTSBURGH DECISION RULES

The Pittsburgh decision rules for optimizing the use of radiography in patients with acute knee injuries
were presented in 1995.31 A prospective observational study was conducted over a 10-month period
in the emergency department of a university hospital. A standardized closed-question data collection
instrument that recorded 12 historical and 26 physical examination criteria was used in the study. A
clinical algorithm for the use of radiography that requires the presence of an inability to bear weight, an
effusion or an ecchymosis was 100 percent sensitive for the detection of knee fractures. No fractures
were found in patients who did not meet one or more of the criteria. Limiting knee radiography to
patients who met these criteria would have reduced the use of radiography by 39 percent without
missing a fracture.

COMPARISON OF DECISION RULES

The Ottawa knee rules and the Pittsburgh decision rules were compared in a prospective study of
patients evaluated in the emergency departments of three teaching hospitals.32 The Pittsburgh decision
rules were 99 percent sensitive and 60 percent specific for the diagnosis of knee fractures and could
have reduced the use of radiography by 52 percent, with one missed fracture. If the rules indicated a
fracture, 24.1 percent of patients actually had a knee fracture (positive predictive value); if the rules
indicated no fracture, 99.8 percent of patients did not have a knee fracture (negative predictive value).
The Ottawa knee rules were 97 percent sensitive and 27 percent specific for knee fractures, with three
fractures missed. The authors of the comparative study concluded that the Pittsburgh decision rules
were more specific, with no loss of sensitivity.

The Authors showallauthorinfo

HOWARD B. TANDETER, M.D., is a lecturer in family medicine at Ben-Gurion University of the Negev,
Beer-Sheva, Israel. After graduating from the Faculty of Medicine at the University of Buenos Aires,
Dr. Tandeter completed a family medicine residency in Beer-Sheva and an academic fellowship at the
University of Toronto, Ontario....

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Coordinators of this series are Thomas J. Barloon, M.D., associate professor of radiology, and George R.
Bergus, M.D., associate professor of family practice, both at the University of Iowa College of Medicine, Iowa
City.

The editors of AFP welcome the submission of manuscripts for the Radiologic Decision-Making series. Send
submissions to Jay Siwek, M.D., following the guidelines provided in “Information for Authors.”

Copyright © 1999 by the American Academy of Family Physicians.

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